Auditor

• Review provider medical records to validate claim data: Codes billed are accurate, complete, and comply with MSO and payer policies
• Codes billed comply with bundling and unbundling guidelines and global period policies
• ICD-10 codes are chosen appropriately and to the highest level of specificity
• CPT and HCPCS codes accurately report the services rendered including level of E&M code in accordance with AMA, CMS, and state-specific coding standards
• Documentation supports billed services under Medicare, Medicaid, and Commercial payer rules
• Identify and report potential coding errors, documentation gaps, or billing inconsistencies that impact reimbursement or compliance
• Collaborate with nurses, medical director, and claims teams to adjudicate/deny claims with coding and/or documentation errors
• Support retrospective and prospective reviews to improve claims accuracy and reduce preventable denials
• Participate in internal audits, education sessions, and process improvement initiatives to enhance coding integrity
• Stay current on updates to CMS regulations, payer billing policies, and industry coding changes
• Protect member and provide confidentiality by adhering to HIPAA and MSO compliance standards

Certified Medical Auditor – Claims Review

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